N Dakota State Cancer and How to Manage the Outbreak

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Mabel Watkins
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1 TB Outbreak Among Off-reservation, Homeless Native Americans Dawn Tuckey, MPH Program Consultant Field Services Branch Division of Tuberculosis Elimination National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Division of Tuberculosis Elimination

2 North Dakota TB Outbreak in the American Indian Population

3 What were the risk factors involved in this Outbreak? Homeless Large number of Household Contacts Substance Abuse (alcohol and street drugs) Small children and babies In 2012, 53% of named contacts were Latent TB Infections (LTBI)

4 Public Health Challenges ` 7 Days a week Directly Observed Therapy (DOT) for all cases and Directly Observed Preventive Therapy (DOPT) for all Children Increased demand for TB testing Lack of Food and Housing Compliances Issues: * Wearing Masks Use of Incentives

5 How Many Where Involved In The OUTBREAK? 31 TB Cases 100 Latent TB Infections (LTBIs) 1800 Contacts

6 Super Spreader AFB smear 4 + Prolonged infectious period for 11 months Delay in seeking medical treatment Misdiagnosed Highly infectious-documented contact of less than 8 hours for conversion

7 Super Spreader Poor historian and would/could not provide any contacts Lead band singer Lived in friends backyard in a tent In and out of jail Stayed at local shelter

8 Super Spreader

9 Other areas of Concern Low-incidence state with limited resources Homeless shelter Correctional facility

10 Continued areas of Concern Lack of Infrastructure to deal with an increase of this magnitude Large number of contacts 100 LTBIs Difficult patients that required a lot of attention

11 Challenges Staffing added Field Staff & Public Health Associate Housing worked with Emergency Preparedness & Response DOT Compliance 7 day DOT Drug Levels non-therapeutic levels

12 Challenges Indian Health Services Developing Partnership Border States and Provinces INH shortage Tubersol shortage

13 Challenges to Contain in order to Manage the Outbreak Manage social barriers to treatment compliance Isolation for infectious cases Housing Food

15 Multi-Agency Coordination North Dakota Department of Health Grand Forks Public Health Department Indian Health Services Centers for Disease Control Regional Training and Medical Consultation Center (Mayo Clinic Center for TB)

16 North Dakota Department of Health s Role Overall responsibility for the outbreak and tracking other cases and contacts to other areas of the state Provided funds for housing, food, cable TV and other essential items for the cases

17 Great Plains Area Indian Health Service s Role Provided a nurse consultant who would help find hard to locate TB patients and contacts through their database Provided medical information from the IHS clinic Flagged medical charts for those contacts needing skin testing

18 CDC s Role Provide technical assistance, personnel and TB onsite training Assist with developing partnerships

19 Program Areas Identified through CDC Program Consultant s Assessment Several patients had low/trace levels of INH was DOT being administered properly? How were the contact investigations being conducted?

20 Program Areas Identified by CDC Program Consultant s Assessment (continued) Decentralized information regarding the evaluation and treatment of TB cases and contacts Lack of case management New State TB Controller

21 Program Areas Identified through CDC Program Consultant s Assessment (continued) Need for basic TB knowledge at the local level No one individual with complete knowledge of the outbreak Need for home isolation monitoring Job roles and responsibilities needed to be better defined

22 Program Areas Identified by CDC Program Consultant s Assessment (continued) Signs and symptom check was not being conducted during DOT Three different electronic systems with no interfacing Identified training and educational needs

23 CDC help is on its way Sent a Public Health Advisor for a month

24 Objectives for the Public Health Advisor Provided general oversight of TB cases and contacts Shadowed epidemiologist and DOT nurse for field and interviewing skills Identified and provided recommendations on the decentralized data systems Assisted the LHD in tracking the LTBIs

25 Objectives for the Public Health Advisor Provided overall guidance to the program Re-prioritized the list of contacts Re-interviewed TB patients Established database management system Helped establish ongoing TB testing at the jail, shelter and temporary labor companies

26 More help is on the way!

27 Regional Training and Medical Consultation Centers (RTMCCs) Nursing Consultants Two nurse consultants were sent for a week to provide on-site training

28 Objectives for the Nurse Consultants Provided training on case management of TB cases and LTBIs Assessed contact investigation process Reviewed field nurse documentation and records management Shadowed DOT nurse Identified dosing concerns with pediatric cases and set up call with RTMCC pediatric physician

29 Objectives for the Nurse Consultants Identified unreasonable treatment protocols and drug monitoring issues Provided recommendations to address these concerns Built peer relationships Provided ongoing case management with new cases

30 Staff attended RTMCC training courses TB Nurse Case Management TB Clinical Intensive TB Contact Investigation: Interviewing Skills Course

31 Requesting CDC Outbreak Help Have the State talk with your CDC TB Program Consultant Submit a request based on needs Epi Aid/Technical Assistance Programmatic Assessment Additional Funding CDC Public Health Advisor Training and Education

32 Acknowledgements North Dakota Department of Health Grand Forks Health Department Great Plains Area Indian Health Service Dee Pritschet, North Dakota TB Program Coordinator

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Centers for Disease Control and Prevention

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Centers for Disease Control and Prevention National Center for HIV, STD, and TB Prevention Division of Tuberculosis Elimination Public